August 26, 2016

The role of research at Kaiser Permanente

Nirav R. Shah, MD, MPH
Nirav R. Shah, MD, MPH

Nirav R. Shah, MD, MPH, senior vice president and chief operating officer for Clinical Operations, Kaiser Foundation Hospitals and Health Plan.

Editor's note: In a recent interview for Science Matters* (SM), Dr. Shah shared his thoughts on our research program and how it is helping to advance Kaiser Permanente’s vision for the future of health care.

SM: What organizational priorities do you believe research can contribute to?

Shah: Research can help us improve quality, safety and affordability. We know where we need to go as an organization; we need to continue to fill in gaps in the continuum of care. We also need to evolve models of care delivery to become even more effective and efficient.

SM: How can research improve the quality of care and service for Kaiser Permanente Southern California members?

Shah: At Kaiser Permanente, we’ve successfully broken out of the academic medical center model of research. That is a big leap forward, because the rest of the country is still using a model standardized decades ago.

We’ve learned that when we see a problem in operations, we may think that we don’t have time for an in-depth review of options in the operational space, but the reality is that we can’t afford NOT to be diligent in our pursuit of the answers .

SM: Can you provide an example of this?

Shah: One that comes to mind is a study led by Sara Tartof, PhD, MPH, that looked at whether or not to immunize surgery patients in the hospital because of concerns it could cause a fever or other issues that might mimic complications of surgery.

On average, more than 200,000 people in the United States are hospitalized each year for respiratory and heart conditions and illnesses associated with seasonal influenza virus infections, according to the CDC. The easiest way to prevent this is to give them the vaccine. It makes sense to offer them the vaccine when we have the chance. Knowing that it is safe to administer the flu vaccine to surgical patients gives us another opportunity to protect people who may be vulnerable to the flu.

It takes a very different mindset as a researcher to be able to work with clinical operations. It also takes flexibility, agility and extreme patience. Because operational colleagues don’t necessarily need to drill down to information about statistical significance — all of this is like speaking in tongues to them. Over time, you have to get to a place where you as a researcher understand where the clinicians and administrators are coming from and then meet them on their terms.

SM: You meet regularly with the Care Improvement Research Team (CIRT). How do you feel the team's work contributes to health care quality at Kaiser Permanente and beyond?

Shah: CIRT is a research model this nation needs to understand and evolve toward because it's tying research to clinical operations in real time so that research influences clinical care, and vice versa. The reality is that there’s a vast chasm now between the two in many places.

We've operationalized how to integrate research into clinical operations and new models of care. The precision of the team’s statistical analysis and the speed with which innovations can be introduced into operations are both significant benefits. It’s not 20 years after you publish a paper that it gets in to the real world — you're answering questions asked by front-line caregivers; hence, care delivery can improve in just a few weeks or months.

We are very excited about the CIRT model and hope that more folks nationwide understand its implications and value and adopt similar models of research in practice for themselves.

SM: You are working on a pilot study that is evaluating the unmet social needs of some members. What is meant by “unmet social needs”?

Shah: Today, we spend 3 trillion dollars as a nation on the health care delivery system. What’s being forgotten is that people don't want more health care — they want better health. To maximize health means looking differently at the kind of care we provide. For our more vulnerable patients, that includes addressing hunger, transportation issues, housing and food insecurity, and other social, nonmedical needs.

The most sensible starting point in addressing unmet social needs is with the roughly 1 percent of Kaiser Permanente Southern California members who account for 23 percent of our total health care costs. Evidence shows that most health care strategies miss the mark with this group, who are known as super-utilizers.

To meet their needs, we recognize that we must do more than provide top-quality health care. We believe that adopting a whole patient perspective for these patients will give us the best chance of improving their health outcomes. The pilot study with Adam Sharp, MD, MS, is assessing the social needs of super-utilizers in three Kaiser Permanente Southern California service areas. From there, we aim to partner with existing community resources, identify gaps in linking with those resources and demonstrate the value of directly addressing the social determinants of health.

SM: Home health is another area of interest to you. Why do you feel this is an important area to study?

Shah: Home health is one part of the continuum that has often been ignored by health care delivery systems, yet it's one of the areas with the most opportunities. At the end of the day, patients want to be at home and not in hospitals or a nursing home. The time has come for us to fully support not only patients, but also their caregivers, so patients can stay at home, especially during times of illness and recovery.

We all want to reduce unnecessary hospitalization. As an example, today at our Riverside Medical Center, we enable a handful of patients to be “admitted” to their home from the emergency room, rather than upstairs to a hospital room. The Advanced Medical Care At Home, or AMCAH Program, is part of a growing “Hospital at Home” movement. What if we could increase that number to 1,000 patients a year, or even 10,000 “admitted” to their homes? It’s an ambitious goal, but if anyone can do it, it will be the physicians and care providers across Kaiser Permanente’s integrated delivery system, powered by Permanente medicine.

SM: Kaiser Permanente is set to open a new medical school in Pasadena in 2019. How do you envision the relationship between the school and research?

Shah: With this endeavor, we are disrupting the accepted paradigm of what a medical school is today, or can be in the future. Our goal is not just to train doctors. It is to train the next generation of leaders in health care. Imparting a deep understanding of clinical research and how to think critically about problems they see every day while delivering care is going to be fundamental to the success of each of these leaders.

SM: What initially drew you to Kaiser Permanente?

Shah: As the New York state commissioner of health, I would often look at what Kaiser Permanente was doing for guidance. I knew I could trust these practices because they were achieved with a certain level of rigor, with real-world, practical implications and workflows taken into account.

Over time, I hoped that New York’s 220 hospitals could rise to the level of the care that Kaiser Permanente provides over 10.6 million members across the country. It was clear that leadership in health and health care nationally was coming from Kaiser Permanente, and I have been fortunate to join this incredible team.

* Science Matters is an internal, bimonthly newsletter for the researchers and staff of the Kaiser Permanente Southern California Region.

Nirav R. Shah, MD, MPH, is the senior vice president and chief operating officer for Clinical Operations for Kaiser Foundation Hospitals and Health Plan. He oversees quality, service, accreditation, regulatory compliance and licensure; as well as nursing, the continuum of care; and the effective use of technology, data and analytics to produce better patient health outcomes. Dr. Shah also is a key liaison with the Southern California Permanente Medical Group for medical education, graduate medical education and research.

Dr. Shah is an elected member of the Institute of Medicine, board certified in Internal Medicine, and is a graduate of Harvard College and the Yale School of Medicine. He was a Robert Wood Johnson clinical scholar at UCLA, attending physician at Bellevue Hospital in Manhattan, associate investigator at Geisinger Health System in central Pennsylvania, and on the faculty of NYU Medical Center in the Section of Value and Comparative Effectiveness. Most recently, he served as commissioner of the New York State Department of Health.